The next morning Kabootri awoke up to find Rupanti, her five-year-old daughter sick and convulsing violently. Rupanti died of AES the same evening, and was buried next to her sister.A

In 24 hours, Kabootri had lost both her daughters even though a government hospital, with five beds for AES patients, is located three kilometres from Jitora Gopalpur village in Chakia Block, a fifteen minute drive from Kabootri’s mud hut.

India’s Parliament is in session for the first time since the Bharatiya Janata Party (BJP) won a second term; but the deaths of hundreds of children in Bihar, where the BJP is running the government in alliance with Chief Minister Nitish Kumar’s Janta Dal (United), may well have happened on a different planet. Neither the government nor the opposition appear particularly concerned.

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“These are poor children of poor people. No one else cares about them,” said Budhan Manjhi, whose three year old daughter, Neha, has also succumbed to the disease in the same village.

The hospital in Chakia, near the Jitora Gopalpur village where Suganti, Rupanti and Neha died within a day of each other, used to be a Referral Hospital, which is meant to provide complex clinical care. It was elevated from a Referral Hospital to an even bigger Sub-Divisional Hospital (SDH) in 2017, but it still only gets a handful of AES cases.

And of the cases that it gets, it refers almost all to the Shri Krishan Medical College and Hospital (SKMCH), an overcrowded tertiary facility, 60 kilometres away in Muzaffarpur.

A social worker, who works with the Bihar government, was at a loss of words.

“This is Bihar,” he said by way of explanation.

Kabootri Devi said nothing.

She sat motionless as her neighbours and relatives tried piecing together the two worst days of her life.

She said nothing as they argued with each other over the hour that the girls were rushed to the SDH, about who accompanied their mother to the “big” hospital in Muzaffarpur, and the time that the girls passed away.

When everyone else was done talking, the grief-stricken mother said, “It all happened so fast that I cannot remember anything. Both my children are dead. No one is left.”

Both my children are dead. No one is left.

A mounting death toll

At 152 and rising, the AES death toll this year is the highest in Bihar since 2014, when the number of dead reached 355.

The causes and symptoms are varied, but in Bihar and Uttar Pradesh, AES is prevalent in communities where children don’t have access to nutritious food, clean drinking water, and sanitation. It hits harder when there are long spells of hot weather.

Ensuring that these poor and vulnerable communities take basic precautions — keeping children from playing in the sun, ensuring that they eat before sleeping, boiling drinking water— is essential to preventing AES.

The Bihar government’s efforts to educate the rural populace about combating AES is far from adequate in any year, but it was practically non-existent, this year. Preparation for the general election, social workers say, took precedence over conducting awareness drives in the months running up to the summer.

Government health care workers, who are tasked with carrying out awareness campaigns in the hinterlands, were deployed on election duty, Arun Shah, head of the Indian Academy of Paediatrics (IAPs) in Bihar, told The Economic Times.

Malnutrition

In Kabootri’s backyard, a steel plate, with rice grains floating in a thin colourless gruel, was attracting flies.

It was last night’s dinner, Kabootri Devi said. Dal with rice or roti is the standard fare in her house. Her family does not starve, but she never had “good food” for her daughters.

Her husband, Sandhu Manjhi, was away in Bengaluru, working a construction job for Rs 200 to Rs 300 per day, when his daughters died. He has since returned.

“We cannot afford eggs and milk,” he said.

Budhan Manjhi, Neha’s father, who is also a labourer, agreed. “We cannot afford it,” he said.

Children with distended bellies, a sign of malnutrition, stood around listening to the grown ups.

What about the village anganwadi, a rural child care centre, where children between the ages of 0 to 6 are meant to get nutritious food?

“Anganwadis have been set up, but the protein that is needed to remove malnutrition is not there,” said Ranjit Kumar, a government doctor, who is the head of the Bihar Health Services Association. “We are also not being able to do health education.”

The social worker, who works with the government, said that the district administration had temporarily closed anganwadis on account of the extremely hot weather.

Another problem, this social worker said, are lengthy power cuts in these parts, which means that children go to sleep early, often without eating.

The villagers of Jitora Gopalpur said that Saturday was the second straight day without electricity.

Jitora Gopalpur is also a village without toilets. Villagers have to relieve themselves in nearby fields.

Betwa Sharma/HuffPost India The sub-divisional hospital in Chakia block of East Champaran in Bihar.

What’s the use?

The government hospital next to Kabootri’s village used to be a Primary Healthcare Centre (PHCs) before it was elevated to a Referral Hospital, and then a Sub Divisional Hospital in 2017.

Until Saturday, this hospital had only nine AES cases - all of which were referred to SKMCH in Muzaffarpur district, which is struggling to cope.

Ten days into the AES outbreak, SKHMC only had 34 beds. A prisoner ward at the hospital has been converted into temporary ward for AES-hit children.

Last week, HuffPost Indiareported that the PHCs located in each district block — meant to be the first port of call for the rural populace — don’t have enough doctors and have been under-utilised in this health crisis.

PHCs, doctors say, were under-resourced for so long that people still don’t believe that they will get proper treatment for something as serious as AES.

Amongst those who come to PHCs, there are few who are treated and discharged. Most are stabilised and then referred to SKMCH.

It is unclear why a SDH like the one in Chakia, which is more sophisticated than a PHC, cannot treat AES patient instead of contributing to the bottleneck at SKMCH.

One doctor here said that the AES ward does not have a ventilator, which rules out keeping critically ill-patients for more than a few hours.

“The government should provide us with these facilities. Only then can we work properly. Only then can we serve the public,” the doctor said.

Senior officials, this doctor said, had instructed them to refer severe cases to SKMCH.

Another doctor pointed out that it had only one ambulance at its disposal.

Others said that some of the worst-hit villages in East Champaran are near the highway, and villagers prefer to head directly to SKMCH.

This SDH is dirty, with garbage and stagnant water in its premises, almost all of which covered in stains and dust. In the ladies’ toilet, there are no doors on the stalls, and water comes out of only two of the three taps in the sinks.

It is also understaffed.

This sub-divisional hospital has vacancies for 27 doctors, hospital official said. It presently has eight including two AYUSH (Ministry of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy) doctors.

“There are only around 2,700 regular doctors working against a sanctioned strength of 11,393 in health services,” Kumar, general secretary of the Bihar Health Services Association, told the Hindustan Times in January this year.

The SDH has two “A grade” nurses against the 50 vacancies, according to hospital officials. Of the 40 ANM (Auxiliary Nurse Midwifery) personnel, who are deployed to administer vaccines in the countryside, it has 26.

Hospital officials say that of the 198 ASHA (accredited social health activist) workers it should have, it has 192, but hospital officials say that 264 are needed for a block with a population of two lakh.

In Chakia, there are eight doctors for over two lakh people.

A doctor at the SDH said, “Do you not know how it is? Why do you look surprised?”

Do you not know how it is? Why do you look surprised?

Ambulance not working

After she found Suganti sick and convulsing on 15 June, Kabootri rushed to wake the men folk who live next door.

Mohan Manjhi, a relative on Sandhu’s side of the family, took charge of the situation on the mornings of 15 and 16 June. Mohan said that both sisters were taken to the sub-divisional hospital, where they were treated for an hour or two before getting referred to SKMCH.

Mohan said that he did not know whether taking Suganti and Rupanti to the sub-divisional hospital was a good idea. He is debating whether it had helped the girls or they had lost precious time.

Budhan, who also took his daughter Neha to the sub-divisional hospital, had similar doubts. “I don’t know if we did the right thing by taking her there instead of Muzaffarpur,” he said.

What Mohan does recall clearly is that on 16 June, when the villagers were calling the sub-divisional hospital for an ambulance to pick Rupanti up from Jitora Gopalpur village, they were told that the ambulance was not available, having broken in another part of the district.

There was no second ambulance at the sub-divisional hospital.

The villagers then rushed to the house of their local ASHA worker, Seema Devi, for help. As she was sick and getting treatment in Muzaffarpur, Mohan asked her husband Dalip Singh to ferry them on his motorcycle to the hospital.

Singh, who was riding the motorcycle, said that Rupanti was convulsing so badly that he could feel her kicking his back as they made their way to the hospital.